S 2435 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-FLECTRICAL PERM1'1'NO.
BIBLDING DIVISION APPLICATIONWERMIT PLUMBING MECHANICAL S 2435
BUILDING PROJEC] NT
'IDEIFICAT )N
BUILDINGADDRESS: SANITARY IS APPLICATION SUBMITTAL.MATE
-22-
DWNE ' AMI7: PHON& CON'I'RACfOR'S NAME: I.IC NU:
NIC CONTROL#
�ARCII .NGINF:k: LIC NO: - ADDRESS: ❑
CON-TACE: PHONE: BUIIAING I'IiRMI'E INFO
❑ Consultant Fees Paid by Applicant(Initial) I11,UG TO I '1OMB ECH
I.ICIiNSI!:DCONTRACIOR'SIlIiC1.ARA]'ION QTY. ELF.CTRICPFItMIT' FEE
1 herehy affirm that I if,licensed under prmis(on of Chapter v(co.nmcremg JOB DESCRIPTION
OWDO with Section]fMNBnfDivision 3ofthe Bmincssand Prnfesi...Cale.and my license is PERMIT ISSUANCE RESIDENTIAL:
F-B(- fall Clue,
eRcc,. ❑SFDWL ❑Kit'CHEN REMODEL
azw Date Claes Limp APPLIANCES-BESIDES PIAL ❑ADDITION ❑PLUMBING RE-PIPE
y<ugl Date Common,
ARCHI fEC'r'S DECI.ARNPION ❑muim-UNIT C1 STRUM URAI.
f.5 h 1'ANIiLS
2pnT� IundcmtunA my plans sbull bO true us puMlc rttnMs MODIhICAI'ION
11P 10200AMPS
Q�•"p ❑IN'f1iN10k El CHIMNEY ltlil'Alk
F+ nt al Licensed Professional 2111-H)WAMPS IMPROVEMENT E]SWIMMy POOLS
CYC; OWNERBUILDERDVCLARA1'ION OVER IOIM)AMPS ❑BATH REMO '1lRlil'Alk ❑D OLIT
C C Q 1 hereby affmn that I mor exempt from the Contractors License law for the
K3MU following reason.Notion 7031.5,Businessland Prefesions Cole:Anycayoresumy, SIGNS ELECTRICAL LJ '
W LLO yaj which fe uires a permit to construct,alter,improve,demolish,or repair any structure
-ah print ts issuance,also requiresthe ppli t tor suchPermit ricasighododuchicat SPLGIALCIRCUITIML'..
F, y ,hath 1' : II rte u H p nn. Ito C L' F 1Cmpmr9
<� Imm40 110
mmeing out Sulmn900(BofO,i,in Jot the Bnsness.nd Plulcon,Cn R)or I'I!MI'.METER01 01.13INS1'. COMMERCIAL:
0.yy o C tow he is exempt,bcml)nm trod the band,he(it,nllcgal exemption.Any violation of ❑NFiW BLDG/ADDI'TIO DEMOL'H N
�H Section AlJlS by any applicant for a permit subjects the applicant to a civil penalty of POWER DE 'CS El TENANT ❑FOODSERVICE.
not more than Five hundred dollars What TENANTP.MLNT
SSC01,m owner of the propeny,or my employees x ith wages as their sole compensation, SWIM GPOOL ELECT RIC
F will do the work,and thestracmre is not intended or offered hassle(Sec.7041.1 easiness DOTHER
0.3 m and Profession C.sic:'Dn Clard s License Luw docs not apply man ravncr of s 'LETS-SWI'fCHP_S-Irl%TUR.
propcny who Thai Ills or improves thereon,and who does such work himself or through
his own employees,provided that such improsens nk ere nm imm�dol nr offered for NEW RESIDENTIAL ELECT'R SQ 17L
sale.If,lewever,the huilding.rimpnrvenunt Luuld within mm yeurnl completion,the S F FL0( SIS
r-builder will have the hulled Of proving loathe did not build or improve for Fur- D D
Iwscofsale).
❑ L as mune,of the pn,peny,i m exclusively connoting with license eoldradmis to IYYIAI': p/ p/
construct the potion See.TTIT.Business and Profession Cade.i i-Conwe,nrI Li- JAN ^ 2 1 99
music Law does not apply it)an owner of Flateny,who builds or innpmvcs thereon.and QTY, PLUMBING PERMIT PEE
who contracts for such projects with a contramminl licensed puauanuo toe Contractor's
Licanso PERMIT ISSUANCE
❑ 1a ,n„ oder sen. .if m P C triad,,earn 1 1 4 B
AI:I'I?K-DRAIN&VI3N'I'-WA'IHR(FA)
O Dom
• WORKER'. COMPENSAIRI DECLARATION HACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury n c of the fallowing declarations:
nt.a,andwill madly eCeni37W ofCe Labor care,far for W.dmswofh- IlRA1NS-Fi00N,R(H)Is.AREA,COND. STORIES TYPETYPE CO N
scion,as which'his
for by Sermon 7]W of roc Labor Gale,fur he perfammncc of the
work fur which this permit is issue. Il%Tl1RFs-PER TRAP
I have and will malnbir Workers CrnOc at did
Insurance,as respired by Section
My Worker
s Cour Codc,for thepefennunacnl the work Our
numbirare permit is Issued. GAS-EA.SYSTEM-I INC40lTfLETs OCC.GROUP AI'N
C. Or: Conn sonsndntinsumuoa currier auntPolicysh.y number oro:
F t
Policy Nix: CAS_EA.SYS]HM-OVER 4(EA) �
CER'DFICATC OF EXEMP PION FROM WORKERS'
COMPENSATION INSURANCE GREASOINDUS'1'RL WASTE INTERCEPTOR
BUILDING DIVISION ILIiS
(This section recd..,he completed A the permit is forote hundred dollars(SIM) GRIASETRAP
or le") I'LANCIIECK FEB.
Icenifyrhm infhc perfmmancenfthewnrkfnrwhichthis permit isissued.isholl SEWER-SANITARY-STORM EA.2W IT.
net employ any person in any monnersu as to heeonm subject to the Workers Comped- ENERGY FEE
Z an Laws of Gditinnia.Dom WAI'EIt HEATER W/VENT'/liLECTR
Z0 Applicam GRADING IFP.
'7-' N NOTICE TO APPLICANT.If,after making this Cedificem of Heemplie 0,you sheuld WATER SYSTEMn RHAHNG
a ; become subject Io he Worker's Compensation provisions of the Labor Code,you mus, SOILS USE
fa7 fontwith rnmply with such provisions o,this permit shall bedeemed revoked.
WATER SERVICE
Q
UO ffiCONSTRUCTION LF I)INGAGENCY NIiW RESIDENTIAL PI.MH, SQ,17L PAID
I hereby unnthaua he.is Owsrumlun lenan
dmgagcy for pertirnnanceof me Rcceip,#
w ,be work for which this permit is isued(Sec.MG.Ci,C.)
O Lenders Name TOTAL:
U Lenders Address TGJIAL:
1 oci ify[hot I have mad,his application and slate that,he above information is BUILDING FEE
Fy corms,.I apace to cmnply with all city and county ordinances and.alam Fawa refining in Q'rY. - MECHANICAL PERMIT FEE
U Z building construction.and hereby imbecilic mtresemmives nf,hi,,i,,amnmr.pordo SEISMIC FEE
above-memiuned pmpcny for inspersion purposes. PERMIT ISSUANCE
(WO)agree to save,indemnify and keep bamdess tire City of Cupertino against11:101ELECTRIC FEE
Fiabili,ies,judgmens,costs and expenses which may in anyway accrue against said City AI:HzRORADDTOMF.CIL
consequence of the gnmting of this permit. PLUMBING FEB
All .ICAN711NUI. STANDS AND WILL COMPLY WITH Ah[.NON-POINT AIR HANDLING UNIT('if)❑I,000CFM)
S RCER:GIILMION5. 1 MECHANICAL FEE
-Z _ AIR HANDLING UNI'I'(OVER 10,00(C ) CONST RUM]ON'I'AX
Signature of ApplicaraComr for Doc li%IIAUST HOOD(W/IIIICry HOUSING MRIGATIONIIiE
IIAZA )ODS MATERIALS :CLOSURIi
I Will the applicant or nmre building oaupanr stow or handle hazardous material HEATING UNIT(TO I0aN l 'U)
us defined by the Cupertino Municip IC c.Chapter).12,and,he health and Safety
Code,Section 255320Uq 1117AIING UNIT(OVP, gAN)BTU)
. I ❑Y, I_' PAID' tiL
VEN'I]LATION -A (SINGI.HRESID) Anle Receipt Will the applicant lir furore building occupant use equipmeal or devices which 11011-HR-CO IJHP OR I W,IXNI BTU)
mi,hazardous air contaminants as definell y the Bay Arca Air Quality Management 'TOTAL:
Disvfell
❑Ye. �� H(IILER MP(OVER 100.000 BTU)
❑
I have read be hv.aNnus materials re uiremena under Chapter LL'15 of the Cali- ATR )NDITIONER ISSUANCE.DATE
f 'a Health R S I Cu I Sections 25505.25511""it255]4.I undermm�J,tali if rho IW RIISIDENI'IAF,MF3CII. SQ.FI'.
7d4ng no,cueontly huvca mnan6,otn it lx ons ousponsihility mnntlfy tbu nnvpnm
aI If,rc remems which must he me r issuance of a Ce 1ficnm rf011ppeary.
P— LZ—
Owner rado....it ager, Date TOTAL: ISSUED IIY:
If OFFICE